Program Operations Manual System (POMS)

A. Evidence mailed directly to DDS

You must upload all evidence, reports, and forms submitted by external sources (e.g.,
the Field Office, claimants, applicants, representatives, and third parties) to the
Certified Electronic Folder (CEF).

When you receive paper source documents, scan the source documents using onsite scanning
or send the documents to the contract scanner. Follow local operating procedures to
determine when to scan documents locally in the DDS or when to send to the contract
scanner.

NOTE: No longer retain documents that are locally scanned in the DDS; once you verify
that the document is accessible in the CEF, destroy it (see Document Retention and
Destruction DI
81020.055).

B. Evidence received via email or CD

When you receive evidence via email or on a Compact Disc (CD), accept and print the
evidence, then add the evidence to the CEF using one of the following actions:

•

scan the evidence using onsite scanning; or

•

send the evidence to the contract scanner.

(Follow local operating procedures to determine when to scan documents locally in
the DDS or when to send to the contract scanner)

If you received the evidence via email, inform the sender that email is not secure
and advise the sender not to send any additional personal information to the DDS via
email. Advise the sender to mail or fax copies of the records, or use the ERE website.

NOTE: Evidence received electronically can be uploaded to the CEF using the Electronic Records
Express (ERE) website. When using ERE to add evidence to the CEF you do not need to
print the evidence. You must use the correct indexing information, including the SSN,
to ensure that the document is added to the correct electronic folder.

Reminder: We consider original medical tests such as x-ray films and original ultrasound pictures
irrelevant evidence and must be returned to the sender. We consider interpretation
reports of such test relevant evidence and must be scan into the CEF. (See Documenting
the Disability Folder - Disability Determination Service (DDS) DI 20503.001).

C. Evidence forwarded by the FO

1. FO faxes evidence to the CEF

The FO may fax medical evidence into the CEF for the following types of cases (per
Receiving Medical Evidence of Record (MER) DI
81010.125):

•

TERI;

•

Presumptive Disability (PD);

•

Quick Disability Determination (QDD);

•

Compassionate Allowance (CAL); and

•

Special arrangement critical cases.

When faxing medical evidence into the CEF, the FO:

•

Annotates the barcode cover sheet with the remark “Faxed into CEF” and includes the
faxing date;

•

Checks the box for “Scanned/faxed documents to follow” on the EDCS Routing Form; and

•

Mails the source documents to the DDS for retention, per Document Retention and Destruction
DI 81020.055.

2. FO sends evidence to DDS

If the FO sends medical evidence directly to the DDS, determine if the document has
been imaged. If the document has not been imaged, follow the directions in DI 81020.060A in this section. If evidence is received from the FO after the case is closed, treat
the medical evidence as trailer material (see Processing Trailer Material for the
Certified Electronic Folder (CEF) DI 81020.140).

D. Evidence mailed to scanning contractor

The contract scanner scans source documents sent directly to them. However, if the
source documents have missing or unreadable barcodes, the contract scanner:

•

Returns the evidence to the DDS; or

•

Scans the documents, which subsequently must be manually indexed by the DDS. For more
information about manual indexing, see Document Management Architecture (DMA) Barcodes
and Document Indexing DI 81020.035.

E. Electronic records express (ERE)

Medical evidence received electronically from ERE-registered providers or copy services
(e.g., SMART Document Solutions, ChartOne) via ERE are automatically uploaded to the
CEF. For more information, see Other Services ER 00101.125.

F. Faxed evidence

If evidence with a DMA barcode is received via fax, it automatically uploads to the
CEF.

G. Evidence received via Health Information Technology (health IT)

The Medical Evidence Gathering and Analysis through Health Information Technology
(MEGAHIT) system obtains medical evidence via health IT by generating an electronic
request to a Health Information Exchange (HIE) if:

•

one or more health IT participating sources are listed in EDCS; and

•

a signed and dated SSA-827 (Authorization to Disclose Information to the Social Security
Administration) image is in the electronic folder (EF).

If there are multiple claims on a case, MEGAHIT transmits only one electronic request
to the HIE.

If there are multiple health IT participating sources listed on the EDCS case, MEGAHIT
sends only one electronic request to the appropriate HIE.

When MEGAHIT sends an electronic request, it adds a “HIT Request” document to the
yellow back section of the EF to identify the following:

•

the listed EDCS source(s) from which health IT records were requested,

•

the HIE(s) processing the request,

•

the requested date range of medical records (when available), and

•

the date the request was made.

1. If medical records data are received

MEGAHIT formats the data into imaged documents (e.g., HIT MER or HIT Extract), which
are stored in the yellow back section of the EF.

2. If no response or no medical records data are received

MEGAHIT adds a “HIT Response” document to the yellow back section of the EF. MEGAHIT
does not generate another request.

NOTE: SSA does not provide payment to the HIE when a HIT Response (rather than a HIT MER)
document is produced. SSA provides payment to the HIE for a valid medical records
response to the initial request that is automatically sent at case transfer from the
FO to the DDS. The DDS provides payment to the health IT participating source(s) for
any additional requests sent by the DDS during case development.